Information Collection

HIC Revolving CS Survey

IC 190164 under ICR 200907-0925-006 · OMB 0925-0604.

Documents and Forms

Document Name Document Type
Form 1 HIC Revolving CS Survey Form and Instruction
1 survey HIC Revolving CS Survey Attachment A 071409.doc Form and Instruction
2 survey HIC Revolving CS Survey Attachment C 071409.docx Form and Instruction
3 survey HIC Revolving CS Survey Attachment D 071409.doc Form and Instruction
4 survey HIC Revolving CS Survey Attachment B 071409.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HIC Revolving CS Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	survey	HIC Revolving CS Survey Attachment A 071409.doc	Yes	Yes	Paper Only
Form and Instruction	2	survey	HIC Revolving CS Survey Attachment C 071409.docx	Yes	Yes	Paper Only
Form and Instruction	3	survey	HIC Revolving CS Survey Attachment D 071409.doc	Yes	Yes	Paper Only
Form and Instruction	4	survey	HIC Revolving CS Survey Attachment B 071409.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 99	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	198	198
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.